Alteration in Comfort: Pain
(_)Actual (_) Potential
| (_)
Musculoskeletal disorder (_) Visceral disorder (_) Cancer (_) Information (_) Trauma (_) Diagnostic test |
(_)
Immobility/improper positioning (_) Pressure points (_) Pregnancy (_) Fear (_) Anxiety/stress (_) Overactivity (_) Other:_____________________________ ____________________________________ ____________________________________ |
| Major:
(Must be present) |
(_) Pt. reports or demonstrates discomfort. |
| Minor:
(May be present) |
(_) Autonomic
response to acute pain:
|
| Date & Sign. |
Plan and Outcome [Check those that apply] |
Target Date: |
Nursing Interventions [Check those that apply] |
Date Achieved: |
| The
patient will: (_) Experience relief of pain A.E.B.
(_) Other: |
(_)
Asses characteristics of pain: location, severity on a
scale of 1-10, type, frequency, precipitating factors,
relief factors. (_)
Eliminate factors that precipitate pain:
eg.:__________________ (_) Offer analgesics q___ hrs prn (according to physician order). (_) Teach patient to request analgesics before pain becomes severe. (_) Explore non-pharmacological methods for reducing pain/promoting comfort:
(_)
Other:________________ |
__________________________
Patient/Significant other signature
__________________________
RN signature
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